ATTACHMENT A

Laguna Honda Hospital &

Rehabilitation Center

Patient Demographics

LHH Distribution of Residents by Race/Ethnicity as of 3/31/06 (n = 1044)

Other Asian12%

Chinese8%Filipino

2%Hispanic

13%

Other2%

Non-HispanicWhite38%

African-American25%

LHH Distribution of Residents by Payor 6/13/06 (n = 1033)

MediCal 93%

Medically Indigent 2%

Private Pay 1%

Medicare 2%

Pending MediCal and/or Medicare

2%

LHH Distribution of Residents by Gender January 2000 - January 2006

47% 47% 48% 48% 47% 49% 48% 49% 49% 51% 53% 53% 51%

53% 53% 52% 52% 53% 51% 52% 51% 51% 50% 47% 47% 49%

0%

20%

40%

60%

80%

100%

120%

Janu

ary 200

0

June

2000

Janu

ary 200

1

June

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Janu

ary 200

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June

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Janu

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June

2003

Janu

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June

2004

Janu

ary 200

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June

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Janu

ary 200

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Num

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iden

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Males Females

LHH Distribution of Residents by AgeFirst Quarter of 2006

0%

5%

10%

15%

20%

25%

<30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 >99

Age Decile

% o

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H Re

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ateg

ory

LHH Distribution of Residents by Age2001 - 2005 and First Quarter of 2006

0%

5%

10%

15%

20%

25%

Perc

ent o

f Res

iden

ts in

Age

Cat

egor

y

Calendar 2001 1% 4% 11% 15% 16% 19% 22% 11% 1%

Calendar 2002 1% 4% 10% 15% 17% 20% 22% 11% 1%

Calendar 2003 1% 4% 9% 16% 18% 19% 22% 10% 1%

Calendar 2004 1% 4% 12% 18% 18% 17% 20% 9% 1%

Calendar 2005 1% 4% 10% 19% 18% 18% 21% 9% 0%

1st Qtr 2006 1% 3% 9% 18% 18% 19% 23% 8% 1%

<30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 >99

c

ATTACHMENT B

Updated June 15, 2006 1 Shading indicates that goal was met.

LAGUNA HONDA HOSPITAL

Strategic Plan Report January 2005—June 2006

MISSION As part of the Department of Public Health safety net, the mission of Laguna Honda Hospital is to provide high-quality,

culturally competent rehabilitation and skilled nursing services to the diverse population of San Francisco. Skilled nursing service includes long-term care for residents who cannot be cared for in the community and/or short-term care for those who can be rehabilitated and discharged to a lower level of care within the community.

VISION Laguna Honda Hospital will be a center of excellence in providing a continuum of care that integrates residents in the least

restrictive setting, thereby supporting their highest level of independence.


GOALS 1. Clinical Programs Continue to enhance preventive and therapeutic clinical programs.

*Paul Isakson, MD, Monica Banchero, MD, Hosea Thomas, MD, Mivic Hirose, RN

Objectives Indicators / Outcomes Baseline Target Current Status

1. Establish a unified behavioral health program.

• Program development and QI Process.

• N/A • Training • QI process

The following PI processes and systems have been implemented: • Resident-to-resident altercations review team. • Staff Incident Review Team • SMART Training • QI data sent to appropriate department heads,

chiefs of service, programs/cluster staff for analysis and action.

• Reallocation and increase in nursing staffing on units identified with behavioral management opportunities.

• Use of 6th floor as open space for dementia residents.

• Improved satisfaction surveys from residents, families, staff.

• 2003 data to be aggregated into single score.

• Press Ganey benchmark • Contract in progress for Press Ganey surveys. • As part of QI program, Nursing interviewed 152

residents, using a quality of life assessment resident interview tool and observed care of 71 residents (not interviewable). Analysis in progress.

2. Enrich culturally focused programs.

• Increased number of bilingual and bicultural staff.

• 76 employees eligible for bilingual pay as of 1/05.

• Increase the number of employees eligible for bilingual pay by 10%.

• 90 employees eligible for bilingual pay as of 5/06.

• Improved satisfaction surveys from residents, families, staff.

• 2003 Data. • Press Ganey benchmark • Establishing pt. sat. survey with Press Ganey. • As above, quality of life assessment is in

progress.

3. Integrate ID/DD program with community.

• 100% assessment completed for ID/DD clients.

• N/A • 7/05 • Open ID/DD unit.

• Completed 7/05 • Opened ID/DD unit in 12/05.


Objectives Indicators / Outcomes Baseline Target Current Status • Increased activity

participation of ID/DD clients.

• MDS N2 Avg Pt. Score* = 0.97 (1/1/05-6/1/05)

• Increase in activity participation by 10% as evidenced by reduction of score in section N2 of the MDS.

• MDS N2 Avg Pt. Score* o All ID/DD = 0.982 (6/05 – 5/06) o Excl. E3 = 0.986 (12/05 – 5/06) o E3 = 0.974 (12/05 – 5/06)

4. Expand rehabilitation/ community reentry program.

• Increase rehabilitation census by 25%.

• In FY 04-05: Acute=1.6 ADC SNF = 17.3 ADC (L4A & L4S)

• Acute = 2 ADC • SNF = 21.63 ADC

• 12/05: Acute= 2.4 ADC SNF = 16.6 ADC • CHCF grant.

* Based on a scale of 0-3, 0 being the highest amount of activity and 3 being the least amount of activity.


2. Safety and Security Develop and implement an enhanced Safety/Security program that will provide a safe/secure environment for residents, staff and visitors. *Gayling Gee, Serge Teplitsky, Cheryl Austin Objectives Indicators / Outcomes Baseline Target Current Status

• Design completed. Installation in progress.

• CH West entrance and rear loading dock entry completed 12/05.

1. Physical Plant Enhancement

• Cardkey exterior door locks. • Improve lighting. • Add duress alarms in North and East

parking lots.

• N/A • 6/05 • 12/05 • 12/05 • System design completed

12/05. Pending P.O. to initiate installation in 6/15/06.

2. Visitor ID

Enhancement • Extend program to day shift at least 3

posts, 7 days per week. • Eves, 2 posts, 5

days per week. • Extend program to day

shift—at least 3 posts, 7 days per week.

• Completed cadet program 3/06. Hours been extended to 4 posts throughout main building and Clarendon.

3. Workplace Violence

Prevention Program (WVPP)

• Establish a violence vulnerability analysis for high-risk units: C3, K6, O7, L4, O4, M5, 2nd Floor of CH.

• N/A • 7/05 • Complete 7/05.

• Cadet recruitment on-going,

with successful staffing of 7 day/week coverage of 4 posts.

• Deputy recruitment in process.

4. Increased Security Personnel –

• Improve response time to incidents. • Intra-campus Escort Service for staff.. • Enhanced Floor/Unit presence (foot

patrols).

• N/A • Emergency < 10 min Urgent < 30 min Other < 60 min • Escort PM & AM shift.

• Completed 12/05.

• One foot patrol/shift/day.

• Completed 6/05.

5. Education and Training • Education and Training regarding the

management of patients with aggressive behavior.

• Minimal training.

• SMART training for high risk units by 1/1/06.

• Train-the-Trainer complete 8/05.


Objectives • Indicators / Outcomes • Baseline • Target • Current Status 6. Traffic and Parking

Enforcement • Implement Paid Parking. • No paid

parking. • 3/1/05 • $563,740 revenue target • Per diem parking by

11/05. • Budget for FY 05-06. • In place by 10/05.

• Complete. Paid parking implemented 3/1/05. Per diem parking in design.

7. Designation of Campus

Safety Officer • Develop a safety officer position. • N/A • Budget FY06

• In Place 10/05 • Position posted 8/05.

Difficulty recruiting. 8. Clean up 3 reported

problems areas on campus.

• Behind Clarendon. • N/A • 4/30/05 • Clean-up behind Clarendon, 3rd and 5th floors complete.

• 5th Floor breezeway closed 1/06. Completed due to closure.

• Clean, trash-free 3rd and 5th floor areas. • N/A • 7/05 • Work initiated on smoking shelters; estimated completion date 6/15/06.

9. Clean up homeless

camps on campus. • Relocate homeless camps, clean up

campsites and patrol. • N/A • 6/05

• Undergrowth removal by 1/1/06.

• Plan completed 4/05. • Camps removal completed

4/05. • Goat project complete 8/05. • Debris removal completed

9/05.


3. Finance Maximize revenue for all programs and services. --- October 2005 review post-Invision --- * Valerie Inouye Objectives Indicators / Outcomes Baseline Target Current Status 1. Submit specific plans

in the FY 06 budget for known opportunities. • Fund position(s) • Staff position(s)

• Increase net per capita patient revenues from one year to next.

• 10/05 • 11/05

• N/A • Budget by 1/05. • Staff by 10/05.

• Complete • Positions posted

2. Convert from the

current ADL system to Invision for patient billing as a short-term solution.

• Obtain proposal from Siemens. • Develop a comprehensive conversion

plan, including a realistic time line. • After conversion, report on reasons for

unbilled services and where reimbursement can be improved.

• Implement operational improvements to capture revenue for the opportunities identified.

• N/A • Conversion by 7/05. • Complete

3. Increase revenue. • Continue to review current operations to

identify additional opportunities. • N/A • After completion of

number 2 above. • On-going

4. Improved Reporting. • Obtain better reporting from the billing

system on services performed where reimbursement can be improved.

• N/A • After completion of number 2 above.

• On-going

5. Improve reporting to

help manage FTEs and operating expenses.

• Obtain consulting engagement to help with nurse model.

• Develop the reports needed by nursing to manage by nursing unit Labor reports, i.e. position control.

• N/A • 7/06 • Planning for improved reporting will take place in FY 06-07.


4. Organizational Structure, Communication and Leadership Develop a hospital-wide organizational structure for operations, leadership, communications, and training. * John T. Kanaley, Gayling Gee, Arla Escontrias

Objectives Indicators / Outcomes Baseline Target Current Status 1. Define and develop

infrastructure. • September 2005 - Nursing, Clinical

& Support Services • Organizational charts.

• N/A • 7//05 • Completed 7/05. • Completed 7/05.

• Staffing plans - o Nursing o DET o Housekeping o Others?

• FTE’s in FY 04-05

• 12/05 • Complete. Developed benchmarks and needs assessments for Nursing, DET and Housekeeping. Submitted Budget request.

• Benchmarks Nursing = 4.1 HPPD DET = 8 FTE Housekeeping = 115

FTE

• 12/05 • Complete

• DET established 8/1/05. • DET strategic goals and objectives

established 11/05. • Complete. Hospital-wide orientation

program updated and revised. Pilot in 5/06.

2. Develop programs to train staff.

• Health Stream, Workplace Safety, Harassment Free Workplace, Cultural Awareness, Abuse, Uniform Discipline, Investigations and Report Writing, Standard of Conduct, Managers’ Training, HIPAA, Compliance, Change Management.

• N/A • Assess for training needs.

• Develop training program.

• Implement

• LHH Education Council established 2/06 with multidisciplinary, hospital-wide representation.

• Quarterly and monthly hospital education calendar established 11/05.


Health Stream program with 90% compliance, June 2006.

• HealthStream Pilot program established 10/05. Sixteen LHH departments enrolled as of 4/06. Barcode reader technology established 3/06. Compliance rates of enrolled departments for 2006 classes ranges from 70-100%. Full roll-out will go into FY 06-07.

Objectives Indicators / Outcomes Baseline Target Current Status 3. Define and develop a

Policy Approval Process.

• Policy approval and review process developed.

• N/A • Policy and Implementation by 6/05.

• Complete. • Reviewed at Exec staff 7/12/05. • P&P Committee established. • Complete. 4. Define leadership

training program, fund, and agree on focus.

• • SYMLOG Baseline Assessment

• 6/06 • Symlog Assessment

• Exec staff Review. • Budget for training FY06

5. Performance

Appraisal Process. • • 19% in 2004 • 80% by 6/05

• 90% by 6/06 • 82.19% for calendar year 2005 on

1/20/06. 6. Design and

implement a communication plan.

• Internal Website. • External Website.

• N/A • 6/05 • 6/05

• Complete 8/05. • Complete 6/05.

• Internal Communication Plan. • Daily Nursing Report.

• 1/06 • 6/05

• Plan complete 3/06. Roll out in FY 06-07.

• Complete 10/05. 7. Build relationships

within DPH and other CCSF Departments.

• TCM Meetings. • Medical staff from both GH &

LHH. • HMA report on leadership.

• N/A • • TCM meetings continue. • 2 medical staff meetings conducted

and I.S.C meetings begun 9/7/05. • HMA Report to HC.


5. Information Systems LHH will participate in the design and implementation of a single DPH-wide clinical and financial information system and will upgrade the hospital infrastructure to support advanced technology. ---October 2005--- * Pat Skala, Mivic Hirose

Objectives Indicators / Outcomes Baseline Target Current Status 1. Develop and

implement a cable management project plan.

• Document and prioritize the replacement of CAD3 wiring throughout the areas that will use Soarian.

• Add data ports (or use wireless access points) to each nursing station to support a minimum of three workstations per nursing unit.

• Place a second and third workstation on each unit as ports become available.

• Need two additional wires pulled to each unit.

• May require wireless devices in cramped areas.

• 6/06 • Completed walk-thru of main building. Walk-thru of Clarendon Hall will be done to identify locations of second device.

• Working with Facilities to identify closest closet. • Have 17 devices on hand to install as soon as wiring is

pulled. • New wiring has been pulled to 14 nursing stations. IS is

working with Nursing to prioritize the rollout of 17 net new workstations on the units. We are in the process of installing these devices now. However, we have reached a point where we can no longer use the existing distribution system to add additional wire. The conduits are full. To avoid the expense of installing a new raiser system in buildings that will be torn down as part of the rebuild project, we will use a combination of wireless technology and Category 3 extenders as we move forward.

2. Staff Training • Partner with the Information

Technology Consortium of San Francisco, City College of San Francisco and Labor to develop a computer-skills training curriculum for staff.

• Computer training needed for 85% of nursing staff.

• 6/06 • As of 5/16/06, currently on a 4th cohort of staff training. Approximately 250 nursing have completed the training.

• Currently on the 4th cohort of staff training. Approximately

250 nursing staff have completed the training.

3. Siemen’s LTC

Programing • Ensure that the Siemens Long

Term Care Requirements document is reviewed, modified and approved by LHH clinical and financial managers.

• N/A • 4/05 • Completed 2/05



4. Define the metrics to be used to measure the success of the Soarian implementation.

• Monitor the work plan. • Project of the LHH IS Steering Committee.

• 9/06

• Brief discussions-have received suggestions. Need to formalize.

• Several proposals have been submitted as possible benchmarking projects. Key from a clinician’s perspective is the need to reduce the amount of time currently spent looking up information in the paper chart and reducing the number of times the information cannot be found.


6. Performance Improvement, Licensing and Regulatory Preparedness Develop and implement the LHH Performance Improvement Plan. --- September 2005 --- * Serge Teplitsky, Paul Isakson, MD

Objectives Indicators / Outcomes Baseline Target Current Status 1. PI Program • Clearly define organization, line

authority, responsibility and accountability for performance improvement.

• LHH Performance Improvement Policy.

• 6/05 • Complete. Program approved and implemented April 2005.

2. Develop Indicators • • CHSRA

• UOs • CMS Quality

Indicators

• Identify significant clinical, financial and organizational outcomes.

• Complete. Indicators are trended and presented at the LHH JCC, Hospital Wide Performance Improvement Committee and Medical QI Committee

3. PI Monitoring • Develop monitoring indicators that

allow organization to track its progress over time and demonstrated the value of care we provide to our residents.

• CHSRA • UOs • CMS Quality

Indicators

• Baseline and Performance measures to be determined by 1/06.

• Complete. Indicators are trended and presented at the LHH JCC, Hospital Wide Performance Improvement Committee and Medical QI Committee

4. Staff Education on Performance Improvement (PI)

• Design presentation of data and information to be shared with employees, the medical staff and the community and to maintain confidentiality of protected health information involved.

• Education through various PI committees.

• Hospital-wide completion by 10/05.

• PI Plan presentation developed. Presented to Exec. Committee.

• Education has been done through presentations at the hospital performance improvement committees and management forums. Training is being designed for Health Stream educational system

• PI Plan was incorporated into LHH new employee orient-ation program on 5/12/06.

5. Program Evaluation • Provide for evaluation of the plan on the regular basis.

• N/A • 6/05 • Complete, evaluation component in PI plan.


7. Human Resources Ensure adequate and culturally competent staff * Robert Thomas, Mivic Hirose, Gayling Gee, Paul Isakson, MD


• Review recruiting and hiring practices.

• LHH employee demographics were reviewed on 4/18/05. LHH is under-represented in relation to our resident makeup and Bay Area population.

• 4/05 • Recruitment practices were evaluated on 8/1/05. The newly designated nursing program director has implemented new recruitment strategies to expand the applicant pool.

Targeted recruitment via:

1. Facilitate a diverse workforce by target recruitment.

• Prepare a target recruitment plan that promotes a diverse workforce.

“

• 7/05

• Job Fairs • Newspaper Ads • Yellow Pages

• Meetings w/ schools of Nursing and community leaders

• Partner with schools and universities to enhance diverse recruitment.

“

• 9/05 “

• Monitor statistics of new employments against LHH and SF populations to achieve a balance.

Employee Racial Demographics 2005 White – 14.6% Black – 11.9% Hispanic – 8.3% Asian or Pacific Islander – 15.1% Filipino – 50.0% Native American – 0.1%

Employee Racial Demographics 3/8/06 White – 13.8% (-0.8%) Black – 11.6% (-0.3%) Hispanic – 8.4% (+0.1%) Asian or Pacific Islander – 16.6% (+1.5%) Filipino – 49.54% (-0.5%) Native American – 0.0% (-0.1%)

Nursing Racial Demographics 2005 White – 4.7% Black – 9.9% Hispanic – 4.6% Asian or Pacific Islander – 6% Filipino – 74.7% Native American – 0%

• Increased recruitment of bilingual/bi-cultural staff by 5% to reflect resident population.

Nursing Racial Demographics 5/06 White – 5% (+0.3) Black – 11% (+1.1%) Hispanic – 5.2% (+0.6) Asian or Pacific Islander – 7.4% (+1.4%) Filipino – 71.2% (- 3.5%) Native American – 0% (same)

2. Enhance the skills of current staff to provide culturally

• Review/survey LHH resident population to determine cultural, social, clinical care needs.

• Nursing and HR are currently analyzing data to determine the language preference of our resident population.

• 6/05 • Department of Education & Training will provide training where there is a language/cultural competency need.



competent care. • Prepare an education and training plan.

• 12/05 “

• Provide education and training for staff to enhance their abilities to provide a diversity of care.

“

• “

3. Minimize staff vacancies and attrition rates.

• Facilitate staff replacement especially in nursing.

• LHH has historically had a low turnover rate. It is anticipated that attrition will increase dramatically in the next few years.

• • Working to improve requisition approval process.

• Survey conducted on expected turnover (1/06): 20% next 3 yrs, 20% next 5 yrs, 34% next 10 yrs.

• Review staff to predict attrition rates.

“ • 6/05 “

• Conduct personal exit

interviews to determine why employees leave.

“

• “

4. Retain a diverse workforce.

• Develop a retention and advancement plan.

• With attrition estimated at 20% over the next 3 years, there is an opportunity to enhance recruitment and retention.

• • Working to improve positive relationships with current staff to enhance morale.

• Working to enhance cultural awareness and values of current staff.


8. Laguna Honda Hospital Replacement Project Develop a systematic approach to successfully operationalize the Replacement Project. --- October 2005 --- *Lawrence Funk

Objectives Indicators / Outcomes Target Current Status 1. In collaboration with the LHH

Replacement Project Team, City/DPH Leadership, and major stakeholders review the project construction bids and budget, and determine the scope of work to be built.

• LHHRP scope: no less than 780 licensed beds.

•

• The East Residence along with the South Residence and Link Building will provide 780 licensed beds for the LHHRP.

• The City has authorized construction of the South, Link and East Resident Buildings which will provide 780 licensed beds. The decision regarding the ultimate scope of the project is a policy issue for City Leadership.

• Decide on remaining scope (the West Wing = 420 beds).

2. Define FF&E Budget and

Procurement process. • Based upon the final scope

of work, review the FFE budget, and develop a plan for procurement.

• Refine budget estimate and produce plan for approving specifications.

• Completed. The total preliminary FFE cost for 1200 costs is $36M, of which $29M is required for 780 beds. The Project Team, consultants, City Purchaser, and LHH staff will collaborate in the procurement process.

3. Develop a Donor Recognition

Policy and Program to support the FFE fundraising effort.

• Program Developed in conjunction with the Laguna Honda Foundation.

• 6-9 months after city makes decision on scope of project.

• The development of a Donor Recognition program has been deferred until ’06-07, pending decision on scope of project and reactivation of the Laguna Honda Foundation.

4. Continue efforts to integrate

technology in the new facility as appropriate.

• To integrate through collaboration LHHRP, hospital staff, DTIS, DPH, IT staff, consultants, optimize integration Every Opportunity.

• Integrate a package from point of care to business systems.

• 1 year prior to opening the facility—8/07.

• Completed 05-06 objective Ongoing in 06-07.

5. Initiate financial planning for

the new facility including a pro-forma operating budget,

• Planning process defined. • By 1/06. • A draft pro forma operating budget has been completed. A final product will be produced when the ultimate scope of the project is determined by


Objectives Indicators / Outcomes Target Current Status and an analysis of the impact of SB1128.

City Leadership.

6. Initiate planning for the

Assisted Living Program on the LHH campus.

• Planning Group established.

• Begin planning as soon as scope of Replacement project is determined.

• Completed objective for 05-06 ongoing in 06-07.

• Develop external website. • Rebuild website.

• By 9/05 • By 9/05

7. Continue to provide public information and advocacy for the Replacement Project. • Community meetings.

• Develop communication plan.

• Bi-monthly • By 1/06

• Completed objective for 05-06 ongoing in 06-07


9. Operational structure of new hospital Initiate the operational planning for moving into the new hospital. --- November 2005 --- * John T. Kanaley

Objectives Indicators / Outcomes Baseline Target Current Status 1. Policy and Procedures To be determined Transition Steering

Committee established and meeting monthly. This will be a 3-yr goal.

2. Operational Plans

a. Nursing b. Operations c. Medical Staff d. Information Systems e. Pharmacy f. Resident/Family g. Licensing/Certification h. Out patient

ATTACHMENT C

Placement Unit Targeted Case Management Accomplishments FY 2005-06

The Placement Unit Targeted Case Management (TCM) program officially began operations in March 2004. It was implemented to help residents of Laguna Honda Hospital transition back into the community and to divert LHH admissions by providing intensive support in securing the resources necessary to remain in the most integrated setting. The TCM program screens, assesses, and develops individual service/discharge plans for LHH residents and San Francisco General Hospital patients who are interested in discharge, and provides limited ongoing case management as appropriate. The TCM Screening identifies candidates eligible for more intensive assessment by case managers for the purpose of possible transitioning back into the community. The TCM Screening criteria include: Level of Cognitive Skills for Daily Decision-Making; Level of Dressing and Personal Hygiene Ability; Suspected Presence of DD or Mental Illness (PAS/PASSR State screening); Availability of Persons Supportive of Discharge; Preference to Return to the Community; and Projected Duration of Stay at LHH. Screening also helps to determine timeframe for potential discharge of those eligible for TCM. In FY 2005-06, as of June 1, 2006, 611 clients were screened for eligibility. The next step in the TCM process is assessment by case managers who evaluate the client’s eligibility for the TCM program through the completion of the RAI-HC. Individual Service Linkage Plans have been developed and are now being processed for each client. In FY 2005-06, as of June 1, 2006, 572 clients were assessed. Once accepted, each client is assigned a case manager who provides discharge planning, makes referrals, and follows the success of the client in the community for a period of time after discharge. In FY 2005-06, as of June 1, 2006, 185 clients were accepted into TCM. A total of 269 clients were served throughout the fiscal year. For these clients, 353 referrals were made to ensure successful community placements. In FY 2005-06, as of June 1, 2006, 119 clients were discharged from LHH and SFGH by TCM staff.

P eriod: 7 /01/2005 - 05/31/2006*

Screenings Completed.......................................................... 611

Assessments Completed...................................................... 572

Clients enrolled into TCM...................................................... 185Discharges from SFGH and LHH by TCM ........................ 119

Community, Wavier and Housing-Related Referrals......... 353

* June 2006 TC M da tase t unava ilab le a t the tim e th is repo rt w as p roduced .

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ATTACHMENT D

EXECUTIVE ADMINISTRATOR John T. Kanaley

HUMAN RESOURCESBob Thomas

NURSING SERVICESMivic Hirose

INFORMATION SYSTEMSPat Skala

MEDICAL SERVICESPaul Isakson, M.D.

Hosea Thomas, M.D.Monica Banchero-

Hasson, M.D.

Clinical & Support ServicesGayling GeeCheryl Austin

QUALITY MANAGEMENTSerge Teplitsky

FINANCEValerie Inouye

Social Services

Surgery

Physician StaffMedical Education

Mental and Behavioral Health

Rehabilitation Services

Support Services

Consult Services

Hematology/Oncology

Cardiology/EKG

Urology

Nephrology

Plastic Surgery

Dental

Pulmonary

Clinical Program

Health & Safety

Clinical Dietitians

See DPH Information Systems Organization Chart

See DPH Finance

Organization Chart

See DPH Human Resources Organization Chart

Operations

Merit Systems

Labor Relations

Payroll

Workers' Compensation

Podiatry

Vascular Surgery

Endocrinology

UCSF Service Agreements

Physician Services

Asian Focus

Acute

High support/Chronic

Complex

Rehab

HiV

Department ofEducation / Training

RAI / MDS Department

Operations

Therapeutic Activities

Activity Therapy

Spiritual Care

Volunteer Services

Palative

Dementia

Materiels Management

Sr Nutrition

LAGUNA HONDA HOSPITALLeadership Team

Clinical Program

Clinical Program

Bed control/Recruitment

Outpt & Clin Support

PT/Rad/RT

Med surg Clinic

IC/CPD

Altzheimer's

HIS

Telecom

Security

Parking/Tran

Housekpng

ADHC

Laundry

Materiels Mgmt

Nutritional Services

PHARMACYDavid Woods

DEPUTY CITY ATTORNEY

Adrianne Tong

ADMINISTRATIVE OPERATIONSRowena Tran

REPLACEMENT PROJECTLarry Funk

COMMUNITY AFFAIRS

Arla Escontrias

Plant Services

Vocational RehabVocational Rehab

February 2006

Medical Director2235 – (1)

MSSD Specialist2106 – (1) Clerk Typist

1424 – (.90)

Daytime

2232 Senior Physician Specialist (32.82)

Nights/Weekends

2230 Physician Specialist (1)

Chief of Psychiatry/SATS

2576 – (1.0)

2232 Psychiatric Senior Physician Specialist

Michael Coleman, MD Charles Stinson, MD

MSSD: Medical Staff Services Department

Ancillary Services

(See Page 2)

Consult Services

2232 Cardiologist(0.13)

NephrologyContract

2232 Urology

2232 Plastic Surgery(0.13)

2232 Surgery(0.14)

DentalUOP Contract

2230 Pulmonary(0.13)

Podiatry Contract

Vascular Surgery Contract

UCSF ServiceAgreements

• Radiology• Neurology• Gynecology• Rheumatalogy• Orthopaedic• Dermatology

LHH Executive Administrator

John Kanaley

Chief of Medicine 2232 – (1)

Chief of Rehabilitation – LHH/SFGH

(UCSF Physician)(See Page 2)

Hematology/Oncology Contract

2230 Endocrinologist (0.13)

Sr. OccupationalTherapist —

Psychosocial2550 – (1.0)

SATS 2930

Psychiatric Social Worker(SATS) (1.0)

SATS2588 R.A.S. (SATS) (1.0)

Secretary II1446 – (1)

Medical Services Division Organizational Chartas of February 1, 2006

Chief of Medical Informatics2232 – (.5)

2430 MEA(EKG Tech.) (2)

Chief of Staff2232 (1)

Ophthalmology Contract

ENT (1)

Vice Chief Psychosocial

Hospital Screening

2576 – (1.0)

NeuropsychologyC&L Coord.

Acute Cluster2576 – (.05)

SATS 2574 – (.6)

PsychosocialCluster/ADHC

2574 (1.25)

Acute Cluster Rehabilitation

(.5)AIDS/M5 (.5)

Admitting2574 – (.06)

Dementia Cluster

2574 – (.65) NeuropsychologyConsult &

Liaison2574 – (1.0)

Nora Wong1.0 FTE Secretary I (1446)

Pamlea Ketzel1.0 FTE Nurse Manager (2322)

Safety Training

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs1428 - 1 FTE

Rosario Enriquez1.0 FTE Nurse Manager (2322)

Units F4 & G6

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Kathleen Maxwell1.0 FTE Nurse Manager (2322)

Units E3 & F5

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Peter Rapadas1.0 FTE Nurse Manager (2322)

Units D6 & F6

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Muriel White1.0 FTE Nurse Manager (2322)

Units M7S & K7

Gail Cobe1.0 FTE Clinical Nurse Specialist (2323)

Dementia Program

Vacant1.0 FTE Clinical Nurse Specialist (2323)

Wound Care/Geriatrics Program

Beautician Services7324 - 2.0 FTEs

Bronwyn GundogduNursing Director (2324)

1.0 FTE

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs1428 - 1 FTE

Ellen Apolinario1.0 FTE Nurse Manager (2322)

Units D5 & E6

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Oliva Ignacio1.0 FTE Acting Nurse Manager (2320)

Units K6 & L6

2320 - 9 FTEs2302 - 18 FTEs

Josephine Rapadas1.0 FTE Nurse Manager (2322)

Units O5 & L7

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Cristina Reyes1.0 Acting Nurse Manager (2320)

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Amparo Rodriguez1.0 Acting Nurse Manager (2320)

Units E5 & M6

Bronwyn GundogduNursing Director (2324)

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Lolita Caceres1.0 FTE Nurse Manager (2322)

Units S300 & W300

2320 - 9 FTEs2302 - 18 FTEs

Daisy Corral1.0 FTE Nurse Manager (2322)

Unit F3 & TTWA Coordinator

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Lilia Hendrix1.0 FTE Nurse Manager (2322)

E100, W100 & E300

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Dorothy White1.0 FTE Nurse Manager (2322)

Units K5 & L5

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Christine Winkler1.0 FTE Nurse Manager (2322)

Units E4 & G5

Mozettia HenleyNursing Director (2324)

1.0 FTE

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Teresita Baluyut1.0 FTE Nurse Manager (2322)

Units C3 & G3

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs1428 - 1 FTE

Natividad DullasActing Clinical Nurse Specialist (2323)

1.0 FTEUnits E200, S200 & W200

2320 - 21.8 FTEs2312 - 3 FTEs

2302 - 75 FTEs1428 - 1 FTE

Madonna Valencia1.0 FTE Nurse Manager (2322)

Units L4A & L4S, Float Staff

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs1428 - 1 FTE

Roland Zepf1.0 FTE Nurse Manager (2322)

Unit O4

Vacant1.0 FTE Clinical Nurse Specialist (2323)

Mozettia HenleyNursing Director (2324)

2320 - 3 FTEs2312 - 2 FTEs

2302 - 15 FTEs

Mercedes Devasconcellos1.0 FTE Nursing Supervisor (2324)

AM Shift

2320 - 3 FTEs2312 - 2 FTEs

2302 - 15 FTEs

Lenora Jacobs1.0 FTE Nursing Supervisor (2324)

PM Shift

2320 - 3 FTEs2312 - 2 FTEs

2302 - 15 FTEs

Sophie Mace1.0 FTE Nursing Supervisor (2324)

AM Shift

2320 - 3 FTEs2312 - 2 FTEs

2302 - 15 FTEs

Monica McGuire1.0 FTE Nursing Supervisor (2324)

PM Shift

2320 - 3 FTEs2312 - 2 FTEs

2302 - 15 FTEs

Mary West1.0 Nursing Supervisor (2324)

AM Shift

Nursing Office2320 - 1.0 FTE, 2302 - 1 FTE

1408 - 1.0 FTE, 1424 - 2.0 FTEs1429 - 2.0 FTEs

MDS/RAI Program2320 - 7.0 FTEs

Vacant Positions2320 - 15 FTEs2312 - 2 FTEs2302 - 7 FTEs

Esperanza SorongonNursing Director (2324)

1.0 FTE

Ghodsi Davary1.0 Nurse Manager (2322)

Admissions Screener/Bed Control

Gigi Ipac1.0 Nurse Manager (2322)

Units M5 & M7A

2320 - 9 FTEs2302 - 18 FTEs

Nahidi Mansoureh1.0 Nurse Manager (2322)

Unit C2Hospice Unit & Palliative Care Program

2320 - 9 FTEs2312 - 3 FTEs

2302 - 18 FTEs

Stella Yim1.0 Nurse Manager (2322)

Units C4 & G4

Anne Hughes1.0 FTE Clinical Nurse Specialist (2323)

Bea Gunn2320 - 1.0 FTE

Clinical Resource NurseClinical Educator

Elisa Ramirez2320 - 1.0 FTE

Orientation CoordinatorClinical Educator

Vacant2320 - 1.0 FTE

Recruitment and Retention Coordinator

Debbie TamNursing Director (2324)

1.0 FTE

Refer to Activity Therapy,Spiritual Care Services,

Vocational Rehabilitation andVolunteer Services Org Chart

William FrazierHealth Program Coordinator (2593)

1.0 FTE

Mivic HiroseHospital Associate Administrator (2145)

Chief Nursing Officer

John T. KanaleyExecutive Administrator

Salary Savings

2302 Nursing Assistant (37.10)

2312 Licensed Vocational Nurse (2.80)

2320 Registered Nurse (14.06)February 2006

LHH Nursing Division

LAGUNA HONDA HOSPITAL OPERATIONS & CLINICAL SUPPORT

DIVISION

* Clinical Oversight

2145Associate Administrator

Clinical and Support Services

1426 Sr. Clerk Typist

Sr. Phone Operator1708 (6)

as needed (1)

Executive AdministratorJohn T. Kanaley

Transportation

2143Director Materials Mgmt

Nutrition Services

7120 (vacant)Director

Facility Services

2786Director

Environmental Services

8205Sheriff Dept.1 Sergeant

2593 DirectorADHC

2114 Asst. Director

Health Info Svcs.

2143Assistant Administrator

Operations

Telecommunication

2924Director

Social Services

Asst. Materials Coordinator

1942 (1)

Asst. Food Svcs Director2660 (1)

Food Svc. Mgr2620 (1)

Sr. Storekeeper1936 (1) Sr. Food Svc

Wrkr Sup.2619 (1)

Materials Coordinator

1944 (1)

Nutrition Services

Storekeeper 1934 (2)

Food Svc. Wrkr. Sup.2618 (2)

Food Srv Worker2604 (68.5)vacant (12)

Supply Rm. Att.2608 (1)

Sr. Food Svc. Wrkr.

2606 (15)

Dietetic Tech2622 (1)

Truck Driver 7355 (2)

vacant (2)

Chief StationaryEngineer 7205 (1)

Sr. Clerk Typist1426 (1)

Maint. Sup7203 (1)

Carpenter7344 (2)

Stationary Engineer 24Hrs

7334 (7)

Stationary Engineer Day

7334 (5)

Electricians7345 (2)

Painters7346 (2)

Plumber7347 (1)

Utility Worker7524 (5)

Sr. StationaryEngineer 7335 (1)

vacant (1)

Medical Social Worker

2920 (17)

Public Service Aid 9924

as needed (1)

Secretary II1446 (1)

Laundry Svcs Mgr2785 - (1)

Porter Supervisor2740 (3)

vacant (2)

Laundry Worker Supervisor2780 - (3)

Asst. Laundry Supervisor

2770 (6) vacant (5)

Laundry Worker2760 (53)

Clerk Typist1424 (1)

Sewing Tech2772 (2)

Truck Drivers7355 (3.5)

Dietician 2624 (7.5)

vacant (0.5)

Asst Cook 2650 (2)

Baker 2652 (1)

Cook 2654 (7)

Chef 2656 (2)

Clerk Typist1424 vacant (1)

Transcriber Typist

1430 (1)

Med. Transcriber

1440 (3)

Med Rec. Clk2110 (11.5)

as needed (5)vacant (5)

Med. Rec.Tech2112 (7)

vacant (2)

File Clerk1404 (1)

Hlth Prog Coord I2589 (1)

Hlth Worker II2586 (1)

Med. Rec. Tech2112 (0.5)

Hlth Wrk I2585 (0.5)

LVN*2312 (0.5)

Medical SocialWorker 2920 (1)

Sr. Social Worker2912 (2)

NP*2328 (0.5)

CNA2302 (4.5)

OT2548 (0.5)

PT2556 (0.5)

Therapy Aide2554 (1)

Sr. Clerk Typist1426 (1)

Gardener3417 (1)

2626Chief

Dietitian

2323Director

Educ & Trng

Registered Nurse2320 (1)

Nurse Manager2322 (1)Material Mgmt

Officers8204 (6)

as needed (2)

Sr. Deputy8306 (2)

Hskp Svcs Mgr2785 (1)

Asst. Porter Sup2738 (3)

Porter2736 (86.1)vacant (7.5)

Utility Worker7524 (1)

2322Nurse ManagerOutpatient.Clinical

Support.Infection Control

Charge Nurse2320

Central Supply RadiologyRespiratory

Lab

CSR Tech.2390 (6)P/T (2)

as needed (5)

Resp. CarePract II2537 (1)

Resp. CarePractitioner2536 (0.5)

as needed (5)

Med. Eval Asst2430 (2)

as needed (20)

Diag. ImagingTech III2469 (1)

Diag. ImagingTech II

2468 (1)

X-Ray Lab Aid2424 (2)

Surgical Clinic

RN2320 (1)

Medical Clinic

RN2320 (1)

LVN2312 (1)

Safety Analyst6130 (vacant)

01/06

ATTACHMENT E

1

Proposal for Training for Laguna Honda Hospital Center for the Health Professions

June 9, 2006 Laguna Honda Hospital: Background and Needs Laguna Honda Hospital (LHH) is a 1,000 bed nursing home, with a staff of 1500 culturally diverse health care providers. In recent years, LHH has experienced a number of challenges and changes, including political battles, difficult budget cycles, cultural tension, and leadership changes. Now LHH is looking toward another large change; in April 2009, LHH will move into a new facility. LHH benefits from having a strong vision – resident-centered care – and a new strategic plan to guide the organization toward its vision. LHH’s Department of Education and Training (DET) is charged in the strategic plan with “serving as a catalyst for achieving the strategic goals of the organization through person-centered, customer-service oriented education and training.” DET identified LHH’s current overarching need as a culture change from a hierarchical model to an interdisciplinary, team-oriented model, in which staff members employ their own critical thinking and creativity to solve problems and implement the strategy in their own roles. LHH needs to be ready to provide resident-centered care in a new home, a high-tech facility which will alter each staff member’s job in some way. Training Intervention Goals

• Entire staff mobilized to work together as a team to implement LHH’s vision of resident-centered care, including culturally competent care

• Culture change from a hierarchical model to a team-oriented model with staff employing their own critical thinking, independence, and creativity

• Culture change linked to strategic plan and upcoming move to new facility Proposed Intervention The Center for the Health Professions (CHP) proposes an intervention with three components: strategic alignment, leadership training, and assessment. Strategic alignment is essential for effective and long-term culture change. As the management and frontline staff are engaging in hands-on change through trainings, top management needs to ensure that the key factors that enable and support this change are in place. These key elements include policies, reward systems, staffing practices, performance evaluations, etc. Top management will receive leadership training that will enable them to lead the change. Training topics will include: Communications, Conflict Management, Teams, Change Management, and Cultural Competency. The executive team will also receive organizational consultation and coaching that will help align them as a team, a key element in aligning the whole organization. As a first step, the executive team will engage in a team development process, including data collection through individual interviews and a data feedback session that engages the executive team in their next steps working together. The purposes of the leadership training for middle management and frontline staff are both to engage the LHH staff as well as to increase the skills they need to work as a broader team to implement the vision. Training sessions are experiential and focus

2

participants on learning that is immediately transferable to their work, enabling staff to enact changes in their own roles. Training both management and frontline staff ensures that staff at all levels share a common perspective, language, and set of behaviors for working as a team toward a common vision. We propose a train-the-trainers model in order to contain costs and to build LHH’s internal capacity. Leadership training for middle management and frontline staff focuses on:

• Cultural Competence and Conflict – This training aims to increase participants’ understanding of the various meanings of culture and the ways in which culture plays a role at work. In addition, the training aims to increase participants’ skills at managing cultural conflict.

• Engaged Conversations/Communication – This training aims to increase participants’ ability to engage in difficult conversations, those interactions that need to happen in order to move strategy forward, but are often either avoided or mishandled due to people’s lack of skills. This training employs numerous role plays as a way for participants to practice their communication skills, including their ability to give and receive feedback.

• Problem-solving – This training aims to increase both participants’ knowledge of problem-solving techniques and their sense of empowerment and accountability, enabling them to be pro-active in solving problems when they see them.

• Change Management – This training provides a framework in which to understand and implement successful change management. Participants learn and practice each of the six key elements of change management – environment, vision, teams, culture, alignment, and action.

• Teams – This training aims to increase participants’ knowledge of teams and how they operate and to increase participants’ ability to be engaged members of successful teams.

In addition to the training sessions, CHP will assist DET in the creation of a training for new managers, including the overall training design and materials, enabling LHH to train new managers internally. The SYMLOG tool will be the primary analytic tool used to assess team and culture value changes as well as identify the need for any further interventions. Initial SYMLOG results from the 2005-2006 RWJ Study which Laguna Honda participated in will inform the initial phasing of the intervention. The results of these first assessments will be presented to the executive team in September 2006. Additional SYMLOG assessments will be conducted for senior leadership in the organization, and at one and two year intervals for the leadership and entire staff to measure perceptions around team effectiveness and organizational culture. The three intervention efforts would be strategically scheduled over the course of 2 years, with trainings provided at intervals to allow staff to implement learnings from one training before attending another. Trainings and strategic alignment consultations would also be strategically scheduled to mutually support each other.

3

Proposed Next Steps The Center proposes to partner with LHH to write a grant proposal to The California Endowment (TCE) to obtain funding for LHH to cover the costs of the training. One of TCE’s funding areas aims “to advance the knowledge, attitudes, skills and experience of health providers and health systems to effectively serve California’s diverse communities.” LHH’s ultimate goal is resident-centered care for a diverse population served by a diverse population of health care providers. The proposed intervention is an integrated set of training, consultation, and assessment aimed precisely at increasing LHH’s internal capacity to serve a culturally diverse population with a culturally diverse staff.

4

Training for Laguna Honda

Preliminary Proposed Budget June 8, 2006

EXPENSES BUDGET IN-KIND CHP Strategic Alignment Development Days 2 days @ $4000/day $8,000 Training Days 5 days @ $8000 $40,000 Assessment Days 3 days @ $8,000 $24,000 Consultation Days 10 days @ $8000/day $80,000 Coaching Days 5 days @ $8000/day $40,000 CHP Strategic Alignment Subtotal $192,000 CHP Training (assuming training 15 trainers)

Development Days 5 days @ $4000/day $20,000 Train-the-trainer Days 5 days @ $8000/day $40,000 Train-the-trainer Co-facilitation Days 30 days @ $4000/day $120,000 Train-the-trainer Ongoing Support 15 days @ $4000/day $60,000 Materials $100/trainer $1,500 New Manager Training Design 5 days @ $4000/day $20,000 Leadership Training Subtotal $261,500 SYMLOG Materials & Scoring $16,000 Results Feedback 4 days @ $8000/day $32,000 SYMLOG Subtotal $48,000 Laguna Honda In-house Expenses Training and Education Staff 1 CNS, 1 NM, 1 RN,

and 1 1426 @ .20 FTE

?Spanish Interpreters for Training Sessions 20 hrs Hlth Worker III ?Chinese Interpreters for Training Sessions 20 hrs Hlth Worker III ?Materials $30,000Offsite Space 50 days @ $300/day $15,000 Food at Training Sessions 30 days @ $300/day $15,000 Food at Combined Exec Training Sessions 20 days @ $1,500/day $30,000 Laguna Honda In-house Subtotal $60,000 TOTAL BUDGET $561,500 In-Kind Total $30,000

5

Beth Mertz Program Director The Center for the Health Professions University of California, San Francisco 3333 California Street, Suite 410 San Francisco, CA 94118 [email protected] Brett Penfil, MPH, MA Program Development Associate The Center for the Health Professions University of California, San Francisco 3333 California Street, Suite 410 San Francisco, CA 94118 Office: 415.476.1271 Fax: 415.476.4113 [email protected] http://www.futurehealth.ucsf.edu

ATTACHMENT F

(415) 759-2363 375 Laguna Honda Blvd. San Francisco, CA 94116-1499

City and County of San Francisco Department of Public Health

Laguna Honda Hospital &Rehabilitation Center

Gavin Newsom Mayor

Office of the Executive Administrator

April 20, 2006 Honorable Michela Alioto-Pier Member, Board of Supervisors Honorable Tom Ammiano Member, Board of Supervisors Honorable Aaron Peskin President, Board of Supervisors Honorable Sean Elsbernd Member, Board of Supervisors Re: Resolution #050396 Dear Supervisors Alioto-Pier, Ammiano, Peskin and Elsbernd: In response to Resolution #050396, I am enclosing a quarterly report to show Laguna Honda Hospital's progress to date on the reversal of the Admission Policy priorities that took place February 22, 2005.

Admissions Sources 2006 - (note: Admissions Policy was changed March 2004 and reversed February 22, 2005) 2005 2004 - Post change to Admissions Policy 2003 - Pre " " " " 2002 - Pre " " " " 2001 - Pre " " " " Quarterly Distribution of Asian Residents since 9/30/01

Ethnicity Distribution 3/31/99 Snapshot 3/31/05 Snapshot 3/31/06 Snapshot 1/1/06 – 3/31/06 Distribution of New Admissions

Age Distribution By percent from 2001 to Present

(415) 759-2363 375 Laguna Honda Blvd. San Francisco, CA 94116-1499

Page 2 April 20, 2006 As you will recall, the Mayor directed Dr. Katz to allow Laguna Honda Hospital's Executive Staff to reverse the Admission Policy priorities back to the pre-March 2004 priorities on February 17, 2005. The policy was changed effective February 22, 2005. Since that time, you will see the percentage of patients coming to Laguna Honda Hospital from San Francisco General Hospital has dropped. The age distribution shows a marked increase in those over 70 years of age and a decrease in those 50 and below from 2004. I am available to answer any questions you may have. I can be reached at 759-2363. Sincerely,

John T. Kanaley Executive Administrator cc: Mitch Katz, M.D.

Director of Health

Gloria Young Clerk of the Board Rebekah Krell Aide to Supervisor Sean Elsbernd

% % % %

Source of Admission Jan SFGH Feb SFGH Mar SFGH Total %

Board and Care 2 3 5 3%

Cal Pac Acute 8 4 3 15 9%

Cal Pac SNF 2 1 3 2%

Chinese Hospital Acute 1 1 1%

Chinese Hospital SNF 0 0%

Home 6 5 9 20 12%

Home Health 0 0%

Kaiser Acute 2 1 3 2%

Mt. Zion Acute 0 0%

Other 2 2 4 2%

Out of County** 0 0%

R.K. Davies Acute 0 0%

R.K. Davies SNF 0 0%

SFGH Acute 23 43% 31 58% 33 55% 87 52%

SFGH SNF 1 2% 0 0% 0 0% 1 1%

St. Francis Acute 3 2 2 7 4%

St. Francis SNF 0 0%

St. Luke's Acute 1 1 1%

St. Luke's SNF 0 0%

St. Mary's Acute 2 2 4 2%

St. Mary's SNF 1 1 1%

Seton Acute 0 0%

Seton SNF 0 0%

UC Med Acute 6 3 3 12 7%

UC Med SNF 0 0%

VA Hospital Acute 1 1 2 1%

VA Hospital SNF 0 0%

TOTAL 53 45% 53 58% 60 55% 166 100%

* Excluding internal transfers

SOURCES OF NEW SNF ADMISSIONS TO LAGUNA HONDA HOSPITAL*JANUARY 2006 - MARCH 2006

% % % % % % % % % % % % %

Source of Admission Jan SFGH Feb SFGH Mar SFGH Apr SFGH May SFGH Jun SFGH Jul SFGH Aug SFGH Sep SFGH Oct SFGH Nov SFGH Dec SFGH Total %

Board and Care 1 1 1 2 5 1%

Cal Pac Acute 1 1 1 4 2 7 2 6 24 4%

Cal Pac SNF 1 1 1 3 1%

Chinese Hospital Acute 1 1 1 1 1 3 2 10 2%

Chinese Hospital SNF 0 0%

Home 3 3 5 8 5 7 7 5 5 4 7 6 65 11%

Home Health 0 0%

Kaiser Acute 1 1 2 0%

Mt. Zion Acute 1 1

Other 1 2 2 1 1 1 2 2 2 14 2%

Out of County** 1 3 3 1 8 1%

R.K. Davies Acute 0 0%

R.K. Davies SNF 0 0%

SFGH Acute 38 79% 34 68% 38 68% 27 60% 26 57% 33 60% 24 55% 29 63% 31 62% 27 60% 26 54% 22 47% 355 61%

SFGH SNF 2 4% 1 2% 2 4% 0% 1 2% 2 4% 2 5% 0% 0% 0% 1 2% 11 2%

St. Francis Acute 2 1 4 1 4 4 2 3 1 4 3 29 5%

St. Francis SNF 1 1 2 0%

St. Luke's Acute 1 1 1 1 1 1 2 8 1%

St. Luke's SNF 1 1 2 0%

St. Mary's Acute 1 1 1 2 5 1%

St. Mary's SNF 1 1 0%

Seton Acute 1 1 2 0%

Seton SNF 1 1 0%

UC Med Acute 2 3 2 1 5 2 2 2 3 2 4 28 5%

UC Med SNF 0 0%

VA Hospital Acute 2 1 1 4 1%

VA Hospital SNF 0 0%

TOTAL 48 83% 50 70% 56 71% 45 60% 46 59% 55 64% 44 59% 46 63% 50 62% 45 60% 48 56% 47 47% 580 100%

* Excluding internal transfers

JANUARY 2005 - DECEMBER 2005SOURCES OF NEW SNF ADMISSIONS TO LAGUNA HONDA HOSPITAL*

Source of Admission Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total %Board and Care 1 1 1 3 0%Cal Pac Acute 4 2 3 3 1 2 2 1 2 20 3%Cal Pac SNF 1 1 0%Chinese Hospital Acute 1 1 1 2 1 6 1%Chinese Hospital SNF 0 0%Home 4 7 3 7 8 1 2 6 6 2 5 3 54 9%Home Health 0 0%Kaiser Acute 1 1 2 1 5 1%Other 1 2 1 5 3 3 1 16 3%Out of County** 1 1 0%R.K. Davies Acute 0 0%R.K. Davies SNF 0 0%SFGH Acute 40 36 64 37 24 35 33 34 31 41 39 42 456 73%SFGH SNF 1 1 2 0%St. Francis Acute 1 5 1 1 2 2 1 13 2%St. Francis SNF 1 1 2 0%St. Luke's Acute 1 1 2 1 2 7 1%St. Luke's SNF 1 1 2 0%St. Mary's Acute 1 3 1 3 5 1 1 2 17 3%St. Mary's SNF 0 0%Seton Acute 1 1 1 3 0%Seton SNF 0 0%UC Med Acute 5 1 1 2 1 1 3 1 15 2%UC Med SNF 0 0%VA Hospital Acute 2 2 0%VA Hospital SNF 0 0%TOTAL 47 56 72 52 41 57 52 51 46 53 46 52 625 100%

* Excluding internal transfers** Out-of-county count begins in October 2004

SOURCES OF NEW SNF ADMISSIONS TO LAGUNA HONDA HOSPITAL*

JANUARY 2004 - DECEMBER 2004

Source of Admission Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total %Board and Care 4 2 2 2 5 2 1 2 1 1 22 4%Cal Pac Acute 2 1 1 1 1 2 8 1%Cal Pac SNF 1 2 1 4 2 1 7 4 1 4 27 5%Chinese Hospital Acute 2 1 1 3 1 1 1 2 2 14 3%Chinese Hospital SNF 0 0%Home 2 3 4 2 9 3 8 12 6 8 3 5 65 12%Home Health 0 0%Kaiser Acute 1 1 1 3 1%Other 1 1 3 2 2 1 2 3 2 2 1 20 4%R.K. Davies Acute 1 1 0%R.K. Davies SNF 1 1 0%SFGH Acute 22 24 17 18 20 20 16 15 19 18 18 19 226 41%SFGH SNF 5 7 4 4 4 3 2 3 7 3 1 5 48 9%St. Francis Acute 2 1 2 3 1 4 3 4 2 22 4%St. Francis SNF 2 1 3 1 3 2 2 2 1 17 3%St. Luke's Acute 2 1 1 1 1 3 1 1 1 12 2%St. Luke's SNF 2 1 4 1 1 1 2 12 2%St. Mary's Acute 3 1 3 3 1 7 3 1 2 1 25 4%St. Mary's SNF 1 2 1 1 1 1 1 8 1%Seton Acute 0 0%Seton SNF 1 1 0%UC Med Acute 1 3 2 4 2 2 4 18 3%UC Med SNF 2 2 0%VA Hospital Acute 1 1 2 0%VA Hospital SNF 1 1 2 0%TOTAL 52 44 42 43 56 41 47 49 52 45 41 44 556 100%

* Excluding admissions from Unit M7



Source of Admission Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total %Board and Care 3 2 1 2 2 1 11 2%Cal Pac Acute 2 2 1 2 1 2 3 1 1 3 3 21 4%Cal Pac SNF 5 3 1 3 2 2 1 17 3%Chinese Hospital Acute 1 3 2 6 1%Chinese Hospital SNF 1 1 0%Home 4 6 6 9 5 10 1 5 5 6 1 5 63 11%Home Health 1 1 0%Kaiser Acute 1 1 1 1 4 1%Other 1 2 3 4 4 1 3 1 2 21 4%R.K. Davies Acute 0 0%R.K. Davies SNF 0 0%SFGH Acute 27 19 29 20 32 20 20 23 24 23 24 29 290 52%SFGH SNF 3 2 4 2 1 1 13 2%St. Francis Acute 1 1 1 3 4 2 1 2 15 3%St. Francis SNF 2 2 2 2 3 3 1 2 17 3%St. Luke's Acute 1 1 2 2 1 1 1 1 3 13 2%St. Luke's SNF 1 2 1 2 1 1 1 9 2%St. Mary's Acute 4 4 2 1 1 1 2 2 2 19 3%St. Mary's SNF 1 1 2 0%Seton Acute 1 2 1 1 5 1%Seton SNF 1 1 0%UC Med Acute 1 1 1 1 3 5 2 2 3 3 4 2 28 5%UC Med SNF 0 0%VA Hospital Acute 1 1 0%VA Hospital SNF 1 1 2 0%TOTAL 46 47 60 47 54 46 42 47 34 48 43 46 560 100%




Source of Admission Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total %Board and Care 3 1 2 2 1 1 2 12 2%Cal Pac Acute 1 1 3 2 2 1 10 2%Cal Pac SNF 4 4 4 1 6 5 5 3 2 2 2 38 7%Chinese Hospital Acute 2 1 1 4 1%Chinese Hospital SNF 0 0%Home 3 7 6 5 7 1 7 6 2 5 2 8 59 11%Home Health 0 0%Kaiser Acute 1 1 2 1 1 6 1%Other 2 1 2 2 3 1 1 3 3 18 3%R.K. Davies Acute 0 0%R.K. Davies SNF 0 0%SFGH Acute 18 18 18 18 21 18 20 34 19 16 15 15 230 43%SFGH SNF 4 6 3 2 5 3 2 4 3 3 35 7%St. Francis Acute 1 3 1 7 3 1 2 5 1 1 2 27 5%St. Francis SNF 2 1 2 3 2 1 1 2 2 1 2 19 4%St. Luke's Acute 3 1 4 1%St. Luke's SNF 1 4 3 3 2 1 2 1 17 3%St. Mary's Acute 5 1 1 3 2 1 3 1 2 19 4%St. Mary's SNF 1 1 2 2 2 1 9 2%Seton Acute 1 1 0%Seton SNF 1 1 0%UC Med Acute 2 1 1 1 1 3 1 1 2 2 15 3%UC Med SNF 1 1 2 0%VA Hospital Acute 1 1 0%VA Hospital SNF 1 1 2 0%TOTAL 51 44 41 38 55 42 51 51 43 38 33 42 529 100%




Laguna Honda Hospital Distribution of Residents by Race/Ethnicity as of 3/31/99 (n = 1024)

African-American25%

Other Asian10%

Chinese7%

Filipino3%Hispanic

12%

Other3%

Non-Hispanic White40%

Laguna Honda HospitalDistribution of Residents by Race/Ethnicity as of 3/31/05 (n = 1057)

African-American25%

Other Asian13%

Chinese7%Filipino

2%Hispanic

12%

Other3%


Laguna Honda HospitalDistribution of Residents by Race/Ethnicity as of 3/31/06 (n = 1044)

African-American25%

Other Asian12%

Chinese8%

Filipino2%

Hispanic13%

Other2%


Laguna Honda HospitalDistribution of Admissions by Race/Ethnicity (1/1/06 - 3/31/06) (n = 364)

African-American23%

Other Asian16%

Chinese4%

Filipino2%

Hispanic12%

Other4%


Laguna Honda HospitalNewly Admitted Asian Residents

Calendar Years 2001 - 2005 and 1st Quarter of Calendar Year 2006(n = 976)

80 6744

3052

9282

74 76

77 126

12841

522

4528

3827 17 7

162

3 3 2 0 2 0 10

Num

ber o

f New

ly A

dmitt

ed A

sian

Res

iden

ts (W

ith R

eadm

issi

ons

Excl

uded

)

Japanese 3 3 2 0 2 0 10

Filipino 45 28 38 27 17 7 162

Asian, Other 74 76 77 126 128 41 522

Chinese 80 67 44 30 52 9 282

2001 2002 2003 2004 2005 2006 (1st Quarter) TOTAL

Prepared for J. Kanaley, Exec. Admin., 2/9/05

Laguna Honda HospitalAll Unique Residents Served

Calendar Years 2001 - 2005 and First Quarter of Calendar Year 2006

0%

5%

10%

15%

20%

25%

Perc

ent o

f Res

iden

ts in

Age

Cat

egor

y

Calendar 2001Calendar 2002Calendar 2003Calendar 2004Calendar 20051st Qtr 2006

Calendar 2001 1% 4% 11% 15% 16% 19% 22% 11% 1%Calendar 2002 1% 4% 10% 15% 17% 20% 22% 11% 1%Calendar 2003 1% 4% 9% 16% 18% 19% 22% 10% 1%Calendar 2004 1% 4% 12% 18% 18% 17% 20% 9% 1%Calendar 2005 1% 4% 10% 19% 18% 18% 21% 9% 0%1st Qtr 2006 1% 3% 9% 18% 18% 19% 23% 8% 1%

<30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 >99

c

ATTACHMENT G

April 27, 2005

FAQ about Laguna Honda Hospital Feb 2006 State Survey

Question. Is there a 274-page state report about resident (patient) abuse at Laguna Honda Hospital (LHH)? Answer: No, there is a 274-page statement of deficiencies issued by the California Department of Health Services as part of the annual license and certification survey required by law for LHH to provide skilled nursing and acute care services. The survey included 18 surveyors who spent almost 2 weeks observing care, interviewing residents (patients), reviewing medical records, inspecting kitchens, smoking areas and etc. The review included incidents involving the over 1300 residents Laguna Honda Hospital cared for between July 28, 2005 and February 21, 2006. Of the 274 pages, only 18 pages (7%) of the report discussed abuse, with 7 identified cases: 3 cases involved arguments between residents, 1 case of LHH confining (secluding) a resident to his nursing unit; according to state law verbal altercations and involuntarily confining a patient to a nursing unit are considered abuse. Only 3 cases which were named in the report involved physical contact between residents, of which no one was seriously harmed. Question. Are there other physical altercations listed in this report? Answer: Yes, the same incidents discussed above are repeated in other parts of the report under different regulations, such as “staff treatment of residents-protecting residents from abuses, “nursing services-not enough staff to supervise residents” etc. There are five other altercations within the document involving dementia patients having altercations with each other. Most occurred on one of our secured dementia care unit.

April 27, 2005

Question. So how many actual altercations were identified in the State survey? Answer: Combining the abuse cases and the others listed under supervising there are

12 Cases: 3 are verbal altercations 1 is an involuntary seclusion (ward restriction) 5 are dementia patients having conflict with other dementia patients 2 are mental impaired due to traumatic brain injuries 1 aids patient who is in a wheelchair.

Of the 8 listed physical altercations, 7 are resident to resident altercations of either dementia patients, or residents with traumatic brain injuries, none of which resulted in serious harm. Note: None of the patients involved were admitted during the patient flow project. Question. What are the other areas cited by the State in this 274-page document? Answer:

The state was concerned about the ability of LHH to supervise residents, and having enough staff (nurses and social workers) to provide the needed care, medication problems, weight loss and nutritional assessments, infection control, urinary catheters, management of pressure ulcers, discharge planning and housekeeping.

Question: Was does it mean that LHH has been found to be providing substandard care? Answer: It means that Laguna Honda Hospital has to make improvements in it’s delivery of care to prevent any altercations from occurring, to increase nursing staffing, to reduce medical error rates, discharge planning, etc.

April 27, 2005

Question: How is Laguna Honda hospital addressing these issues ? Answer: Laguna Honda hospital takes these licensing deficiencies very seriously, the nursing staffing has been increased, there is an automated unit dose medication distribution system being piloted to reduce medication errors, there are significant investments being made in training programs to improve supervision and interactions with Residents, There have been investments in improved Activities to channel residents into more positive resident to resident interaction, there are improved nursing protocols for pressure ulcers, etc. I hope this information helps to clarify any rumors of there being a 274 page report of elderly abuse occurring at LHH. Sincerely John T. Kanaley Executive Administrator Laguna Honda Hospital and Rehabilitation Center.

ATTACHMENT H

DRAFT revised 5-16-06 1

LAGUNA HONDA HOSPITAL

Strategic Plan July 2006—June 2007

DRAFT

MISSION

As part of the Department of Public Health safety net, the mission of Laguna Honda Hospital is to provide high-quality, culturally competent rehabilitation and skilled nursing services

to the diverse population of San Francisco. Skilled nursing service includes long-term care for residents who cannot be cared for in the community

and/or short-term care for those who can be rehabilitated and discharged to a lower level of care within the community.

VISION

Laguna Honda Hospital will be a center of excellence in providing a continuum of care that integrates residents in the least restrictive setting, thereby supporting their highest level of independence.


GOALS

1. Clinical Programs *Paul Isakson, MD, Mivic Hirose

Enhance therapeutic and preventive clinical programs.

Objectives Indicators / Outcomes

1. Continue the development of specialty practice that incorporates evidence-based care, best practices, resident centered care and training for the following programs:

• ID/DD • Dementia • HIV/AIDS • Rehabilitation • Community Reentry • Wound Care • Palliative Care • Resident Development and Education

• Patient Satisfaction • MDS Data • Staff Satisfaction

2. Expand HIV/AIDS Program capacity within the LHH continuum of care, including care of the

resident with HIV dementia. • Admission Waiting List • Patient Satisfaction • # beds allocated to HIV/AIDS

3. Expand Rehabilitation Services and Program • # staff dedicated to rehab both on the units and

in the department, including therapists, etc 4. Medication management and safety initiatives.

• Improve efficiency of the medication administration process (minutes/medication administered).

• Reduce the likelihood of medication dispensing & administration errors by providing oral solid medications in unit dose packaging.

• MDS Data • Unusual Occurrences

5. Manage Behavioral Health through a Multidisciplinary Approach.

• Decrease aggressive behaviors • Decrease reportable behavior problems • Decrease problem smoking


2. Education and Organizational Development *Gayling Gee

Serve as a catalyst for achieving the strategic goals of the organization through person-centered, cutting edge, customer-service oriented education and training.

Objectives Indicators / Outcomes 1. Establish a Hospital organization structure that insures integration and coordination of all

resident-centered educational activities to tier up to a single oversight under DET.

A. Develop a hospital-wide P & P for educational standards, specifically to define DET responsibilities and inter-departmental roles and responsibilities to insure compliance with regulatory requirements.

A. Review and revise LHH Policy 80-5 “Staff Development” to reflect DET responsibilities and inter-departmental roles by March 30, 2006. Final P&P approval by July 30, 2006.

B. Establish protocols for developing educational content, attendance and record-keeping and communicating/coordinating with DET.

B. Develop protocol by March 30, 2006. Adoption by LHH Education Council by July 30, 2006.

C. Implement training on protocols for staff identified as departmental educators.

C. Identify departmental educators by March 2006. Complete training on protocols by September 30, 2006.

D. Utilize LHH Educational Council to ensure integration of mandatory, regulatory and

clinical education programs.

D. Establish monthly meetings with identified departmental educators and distribute monthly meeting minutes to all members by July 30, 2006.

2. Integrate the LHH philosophy on organizational development and change management into

hospital-wide orientation and all training programs.

A. Collaborate with Executive Staff to develop the philosophical framework for organizational development and change management.

A. Coordinate a series of Executive staff meetings to develop philosophical framework. Initiate by July 30, 2006.

B. Coordinate leadership and change management training for Executive and Management staff.

B. Initiate leadership training by September 30, 2006.

C. Incorporate the philosophical framework into the LHH orientation program.

C. Initiate by September 30, 2006.


D. Develop and implement a LHH-wide education program on change management.

D. Develop plan by September 30, 2006. Initiate plan by November 30, 2006.

E. Develop outcome indicators on SYMLOG survey results to monitor effectiveness of

training efforts. E. Develop a plan for use of SYMLOG survey

results by July 30, 2006.

F. Collaborate with clinical leaders and Resident Council, Family Council and Ombudsman to incorporate organizational philosophies into resident orientation and education.

F. 1) Establish working group w/ Resident Council by September 30, 2006. 2) Develop Resident Orientation program by March 30, 2007.

G. Develop educational grant proposals to leverage educational resources. G. Identify grant proposal opportunities, and

develop and submit a grant proposal for organizational development by September 30, 2006.

3. Optimize computer-based training to facilitate technological competence, enhance safety

and quality of care, and maintain regulatory compliance.

A. Implement HealthStream hospital-wide, improve timeliness and compliance, train managers to access database and produce reports and documents.

A. 1) Continue to roll out HealthStream to non-nursing departments—All non-nursing departments to be completed by December 31, 2006. 2) In collaboration with Nursing Department, develop a plan to begin using HealthStream for on-line education by March 30, 2006. 3) In collaboration with Nursing Department, develop a plan to enroll identified “computer literate” nursing staff on HealthStream by March 30, 2006.

B. Establish staff training and support systems to insure Invision/net access.

B. Form a workgroup with DET/IS/Nursing to develop a training plan for use of the INVISION/NetAccess software by July 30, 2006.


C. Establish staff training and support systems for Soarian application.

C. Collaborate with SOARIAN project leaders to determine training protocol based on SOARIAN live date. Completion date TBD.

D. Establish staff training and support systems for other, computer based operational applications.

D. Conduct computer competency needs assessment for non-nursing departments by September 30, 2006. (Nursing Department completed their staff assessment in summer of 2005)

4. Refine systems for empowering managers to track and support training requirements as part

of the competency-based performance appraisal process.

A. Maximize the use of the HealthStream database to centralize all educational documentation.

A. Develop a plan to assure capture of non-HealthStream training courses in the HealthStream database by September 30, 2006.

B. Train managers to utilize the database to input, extract, and document training-related information.

B. Conduct training of identified managers to utilize HealthStream database to assist them in completing employee performance appraisals by December 30, 2006. 100% of trained managers will use HealthStream education transcripts as part of employee performance appraisal process.


3. Safety and Security *Gayling Gee

Enhance the Safety and Security Program.

Objectives Indicators / Outcomes 1. Increase security measures through implementation of the following:

A. Develop and implement a plan to maximize use of interior and exterior camera monitoring system.

E. Develop and implement by July 1, 2007.

B. Establish a satellite Sheriff’s post at the third floor breezeway between the E and K wings.

F. Complete site by September 30, 2006.

C. Develop and implement a plan to further secure building access points, especially between hours of 6:00PM to 6:00AM and to insure adequate patrolling of high risk areas.

G. Develop and implement by September 30, 2006.

D. Develop and distribute a quarterly Safety/Security newsletter.

H. Distribute first issue by July 30, 2006.

2. Compile available security data, analyze and develop recommendations to minimize security

breaches.

A. Evaluate response times to incidents on a quarterly basis and initiate actions to improve response.

H. Initiate by September 30, 2006.

B. Evaluate and modify patrol routines based on security data analysis.

I. Initiate by September 30, 2006.

3. Continue monthly Threat Assessment Team meetings.

A. Evaluate how SFSD and clinical staff implement their roles and responsibilities in the following processes:

• SMART • Assist Team • Dr. Gray • SIRT

E. Initiate by July 30, 2006.


4. Review and revise the LHH Safety Program.

A. Review and revise the LHH Safety Committee Structure.

A. Complete by September 1, 2006.

B. Review and update the LHH Safety Manual. B. Complete by October 1, 2006.

C. Review and revise the LHH Safety Training Program. C. Complete by December 30, 2006.

5. Review and revise the LHH Emergency Response Plan.

A. Review and revise the LHH Emergency Response Plan.

A. Complete revisions by September 1, 2006. Final policy approval by December 30, 2006.

B. Incorporate the HEICS model into the LHH Emergency Response Training. B. Complete by September 1, 2006.

C. Conduct semi-annual hospital-wide Emergency Response drills utilizing the HEICS model.

C. Initiate October 1, 2006.


4. Organizational Structure, Communication and Leadership *John Kanaley

Strengthen LHH’s Infrastructure, Improve Communications and Enhance Leadership.

Objectives Indicators / Outcomes 1. Implement hospital infrastructure improvements per our budget initiatives. • October 2006 2. Develop a set of cultural values to incorporate into our mission and vision. • February 2007 3. Support the Completion of Hospital-wide Performance Appraisals. > 90% December 2006 and July 2007 4. Enhance Communication Plan

Staff Residents & Families Community

5. Support Department Customer Service Infrastructure •

Cleanliness Materials Management, Supplies, Contracts, BPO’s, Automated Inventory Control Office machines Computers upgraded Phone Book Project Management – Moves & Renovations

6. Continue to Clean Up Valley • Waste site Clean up Maintenance Plan Bike & Walking trail Goats again

7. Build on Relations within DPH and other City Organizations • TCM Long-term Care Coordinating Council Integrated Steering Committee Mental Health Services AIDS Office Labor


5. Budget, Finance and Revenue * Valerie Inouye

Maximize revenue, financial support and fiscal responsibility for all programs and services.

Objectives Indicators / Outcomes 1. Review MDS documentation and coding. 2. Analyze billing reports.

A. Reasons for denials, how to prevent denials B. Pro fee billing and collections by clinician C. Utilization of clinic and ancillary services D. Form work groups, as necessary, to resolve billing issues

3. Periodically interview clinicians to determine if there are any new services provided or new

supplies used. Update encounter forms and charge description master as necessary.

4. Facilitate a fiscally responsible budget which maximizes clinical services and maximizes

revenue for all programs, services and infrastructure.


6. Information Systems * Pat Skala

LHH will participate in the design and implementation of an integrated clinical and financial information system and will upgrade the hospital infrastructure to support advanced technology.

Objectives Indicators / Outcomes 1. Develop and implement a cable management plan. Prioritize the replacement of CAD 3 wiring

in all clinical and administrative locations.

2. Work toward the placement of three computing devices on each nursing unit. 3. Define the metrics to be used to measure the success of the Soarian implementation at LHH. 4. Interface all LHH transcribed reports to Soarian Clinical Reports. 5. Continue to develop computer-skills training curriculum for staff. 6. Improve Desktop Support Services


7. Quality Management

*Serge Teplitsky Ensure regulatory compliance and performance improvement.

Objectives Indicators / Outcomes 1. Enhance LHH Performance Improvement Program to include a structure to review resident-to-

resident altercations and other resident safety issues.

2. Develop and implement departmental performance improvement indicators. 3. Conduct a resident, family and staff satisfaction survey (Press Ganey). 4. Develop and implement internal multidisciplinary survey process to assure continuous regulatory

compliance and preparedness

5. Develop educational program for performance improvement and maintaining regulatory

compliance.

6. Establish a resident response program to diffuse incidents and altercations.


8. Human Resources

*Robert Thomas Achieve and maintain staffing levels to effectively meet the complex residents needs and programs.

Objectives Indicators / Outcomes 1. Enhance Employee Morale, Obtain Baseline data from Staff Satisfaction Survey; identify top three items for improvement.

2. Minimize staff vacancies. 3. Facilitate a diverse and culturally effective workforce by target recruitment.


9. Laguna Honda Hospital Replacement Project

*Lawrence Funk Develop a systematic approach to successfully build and initiate the operational planning for the new Hospital.

Objectives Indicators / Outcomes 1. Produce plans, systems and schedules to successfully manage the activation of the new

hospital

2. Implement the planning and procurement process for the furniture, fixtures and equipment

(FF&E).

3. Retain consultants to support each department in optimizing workflow efficiency in the new

facility through design review and development of operational plans.

4. Continue efforts to identify and integrate technology, which will increase quality of care and

productivity in the new facility.

5. Refine resident and departmental move plans. 6. Identify research topics for measuring improved outcome indicators in the new facility. 7. Initiate remodel work in areas of the existing Main Building, which will be preserved. 8. Evaluate opportunities to test efficacy of design elements of the new facility where feasible.

Areas evaluated may include: • Medication dispensing systems • Unit Galleys • Unit Bathrooms • Resident Laundry • Flooring Materials

ATTACHMENT A

Documents

Transcript of ATTACHMENT A